A 38-year-old woman has a history of rheumatoid arthritis, and she is currently receiving immunosuppressive therapy including corticosteroids. On physical examination she has minimal erythema, warmth, and swelling of the small joints of her hands. Laboratory studies show Hgb 10.1 g/dL, Hct 30.4%, MCV 88 fL, WBC count 6500/microliter, and platelet count 137,000/microliter. Her reticulocyte count is 1.5%. She has a serum iron of 28 microgm/dl and iron binding capacity (TIBC) of 200 microgm/dl. Her serum ferritin is 420 ng/mL. Which of the following is the most likely diagnosis?
A Chronic blood loss
B Beta-thalassemia
C Anemia of chronic disease
D Autoimmune hemolytic anemia
E Corticosteroid therapy
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A 5-year-old girl has had a sore throat and runny nose for the past week. On physical examination she has bilateral tender cervical lymphadenopathy. One of the enlarged cervical lymph nodes is biopsied. Microscopically the node demonstrates prominent, well-defined paracortical follicles with germinal centers. Scattered macrophages are seen within the sinuses. Which of the following is the most likely diagnosis?
A Small lymphocytic lymphoma
B Myeloproliferative disorder
C Multiple myeloma
D Lymphoblastic leukemia
E Reactive hyperplasia
A 30-year-old man has noticed a progressively worsening productive cough for one month. On physical examination, a few small non-tender lymph nodes are palpable in the axillae, and the tip of the spleen is palpable. There is dullness to percussion of the left lung base. A CBC shows Hgb 10.2 g/dL, Hct 31.1%, MCV 90 fL, platelet count 36,000/microliter, and WBC count 67,000/microliter. Examination of his peripheral blood smear shows blasts with Auer rods. Which of the following is the most likely diagnosis?
A Acute myelogenous leukemia
B Plasma cell leukemia
C Chronic lymphocytic leukemia
D Acute lymphoblastic leukemia
E Leukoerythroblastosis
A 64-year-old woman is scheduled to undergo an elective hernia repair. She reports increasing tiredness over the past year, which she attributed to job-related stress. She has no lymphadenopathy and no hepatosplenomegaly on physical examination. As part of a preoperative workup, she had a CBC that shows a total WBC count of 26,000/microliter, Hgb 11.2 g/dL, Hct 33.3%, MCV 90 fL, and platelet count 163,000/microliter. The peripheral blood smear shows many small, mature lymphocytes. Which of the following conditions is she most likely to have?
A Leukemoid reaction
B Acute lymphocytic leukemia
C Infectious mononucleosis
D Cytomegalovirus infection
E Chronic lymphocytic leukemia
A 51-year-old woman has been feeling tired for the past 7 months. She is found to have decreased sensation to light touch and pinprick over the lower extremities on physical examination. A CBC demonstrates the following findings: Hgb 9.5 g/dL, Hct 29.1%, MCV 124 fL, platelets 250,000/microliter, and WBC count 8200/microliter. The reticulocyte count is 0.5%. Hypersegmented neutrophils are seen on examination of his peripheral blood smear. Which of the following laboratory tests is most appropriate to order next on this woman?
A Serum B12 and folate
B Bone marrow biopsy
C Serum ferritin
D Hemoglobin electrophoresis
E HIV antibody test
A 42-year-old man has become increasingly lethargic for the past 4 months. He becomes febrile with a bout of pneumonia. A CBC shows: Hgb 10.3 g/dL, Hct 30.8%, MCV 88 fL, platelet count 87,0000/microliter, and WBC count 189,000/microliter with differential count 69 segs, 10 bands, 3 metamyelocytes, 3 myelocytes, 1 blast, 6 eosinophils, 4 basophils, 2 lymphocytes, and 2 monocytes. The leukocyte alkaline phosphatase score is low. A bone marrow biopsy is performed and on microscopic examination the marrow is 100% cellular. A cytogenetic analysis on cells from the marrow is most likely to show which of the following karyotypic abnormalities?
A t(8;14)
B t(15;17)
C t(14;18)
D t(1;19)
E t(9;22)
A 59-year-old man has had worsening sensitivity to cold for the past year. His fingers turn cold and blue upon exposure to cold. He now puts gloves on when he gets food out of the refrigerator. On physical examination, he does not have hepatosplenomegaly or lymphadenopathy. A bone marrow biopsy is performed and on microscopic examination shows a slightly increased number of plasma cells that mark equally with both kappa and lambda. In the peripheral blood are both IgM and IgG cryoglobulins. Which of the following infections is most likely to be associated with these findings?
A Malaria
B Hepatitis C
C Parvovirus
D Epstein-Barr virus
E HIV
A 69-year-old man has had chronic back pain for 5 months. He has also lost about 5 kg. On physical examination he is afebrile. Laboratory studies show a WBC count of 9800/microliter with differential count of 63 segs, 7 bands, 2 metamyelocytes, 2 myelocytes 18 lymphs 8 monos, and 4 nucleated RBC's. The Hgb is 12.2 g/dL with Hct of 37.1%, MCV of 84 fL, and platelet count of 124,000/microliter. Which of the following is the most likely diagnosis?
A Hemolytic anemia
B Chronic lymphocytic leukemia
C Staphylococcus aureus osteomyelitis
D Previous splenectomy
E Metastatic carcinoma
A 70-year-old man has had progressive fatigue for the past year. He notes easy bruisability. He has had a series of upper resptiratory tract infections. On physical examination he has splenomegaly but no lymphadenopathy. A CBC shows a Hgb of 10.6 g/dL, Hct 29.8%, MCV 92 fL, platelet count 25,000/uL, and WBC count 2,900/uL. The WBC differential count shows 67 segs, 4 bands, 2 metamyelocytes, 22 lymphs, 5 monos, and 2 nucleated RBC's per 100 WBC's. There are occasional tear drop cells on examination of his peripheral blood smear. Which of the following is the most likely diagnosis?
A Disseminated intravascular coagulation (DIC)
B Parvovirus infection
C Hereditary spherocytosis
E Myelofibrosis
A 45-year-old man has had pruritis for the past 8 months. On physical examination he has a ruddy complexion. His spleen tip is palpable. Laboratory studies show Hgb 22.3 g/dL, Hct 65.7%, MCV 89 fL, MCHC 33.9 pg/mL, MCH 34.2, platelet count 445,000/microliter, and WBC count 12,500/microliter with 80% segs, 5% bands, 3% monos, and 7% lymphs. A urinalysis shows no remarkable findings. Which of the following is the most likely diagnosis?
A Chronic myelogenous leukemia
B Polycythemia vera
C Miliary tuberculosis
D Epstein-Barr virus infection
E Dehydration
F Centrilobular emphysema
G Renal cell carcinoma
A 30-year-old woman has had a non-productive cough for the past 3 days. On physical examination her lungs are clear to auscultation. She has a temperature of 37.3 C. Laboratory studies show a WBC count of 10,500/microliter with differential count 61 segs, 3 bands, 15 lymphs, 8 monos, and 13 eos. Infection with which of the following organisms is most likely to produce her illness?
A Ascaris lumbricoides
B Cryptococcus neoformans
C Mycobacterium tuberculosis
D Parainfluenza virus
E Streptococcus pneumoniae
A 62-year-old man has had increasing lethargy for the past 6 months. On physical examination there are no abnormal findings. Laboratory studies show his serum urea nitrogen is 42 mg/dL with creatinine 4.6 mg/dL. A urinalysis dipstick examination shows no protein, but the sulfosalicylic acid test is positive. Serum protein electrophoresis reveals a 4 gm monoclonal gamma spike. Which of the following laboratory test findings is this man most likely to have?
A Lymphocytosis
B Elevated sedimentation rate
C Positive antinuclear antibody test
D Hypocalcemia
E Macrocytic anemia
A 23-year-old woman from West Africa has been mildly fatigued for the past year. On physical examination she has scleral icterus. Laboratory studies show Hgb 10.4 g/dL, Hct 30.8%, MCV 70 fL, platelet count 278,300/microliter, and WBC count 7390/microliter. Examination of her peripheral blood smear shows numerous target cells, and some RBCs contain hexagonal crystals. Her total serum bilirubin is 4.2 mg/dL with direct bilirubin 0.7 mg/dL. Her serum haptoglobin is 155 mg/dL. Both the direct and indirect Coombs tests are negative. A hemoglobin elecrophoresis is most likely to detect an increased amount of which of the following hemoglobins?
A Bart's
B C
C E
D F
E H
E S
A 91-year-old man has had fever and back pain for the past week. During he past day he has become delirious. On physical examination he has vital signs with T 38.5 C, P 100/minute, RR 20/minute, and BP 90/40 mm Hg. Laboratory studies show a Hgb of 11.5 g/dL, Hct 34.2%, MCV 90 fL, RDW 20, platelet count 37,000/microliter, and WBC count 13,400/microliter. A "helmet cell" (a type of schistocyte) is seen on examination of his peripheral blood smear. His serum haptoglobin is 2 mg/dL. Which of the following underlying conditions is he most likely to have?
A Beta-thalassemia
B Adenocarcinoma of the colon
C Escherichia coli septicemia
D Hereditary spherocytosis
E Massive splenomegaly
A 45-year-old man has complained of headache and dizziness for the past 2 weeks. Physical examination reveals a palpable spleen tip but no lymphadenopathy; his complexion appears plethoric. A bone marrow biopsy is performed and on microscopic examination shows 98% hypercellularity with myeloid, erythroid, and megakaryocytic cell lines increased in number. Which of the following sets of peripheral blood findings is most likely to be present in this man?
A WBC differential count: 80 segs, 14 bands, 4 lymphs, 1 mono, 1 eosinophil
B CBC with Hgb 20 gm/dl, Hct 61%, and MCV 92 fL
C Total lymphocyte count of 200 per microliter
D CBC with Hgb 10 gm/dl, Hct 30%, MCV 85 fL, platelet count 3,000/microliter
E WBC differential count: 59 segs, 3 bands, 18 lymphs, 5 monos, 15 eosinophils
A 13-year-old boy has the sudden onset of severe right hip pain. On physical examination he is afebrile, but there is marked pain on movement of his right hip, with reduced range of motion. A pelvic CT shows avascular necrosis of the right femoral head. Laboratory studies show Hgb 9.6 g/dL, Hct 29.1%, MCV 98 fL, platelet count 185,600/microliter, and WBC count 5845/microliter. A Hgb electrophoresis shows 95% Hgb S, 4% Hgb F, and 1% Hgb A2. Which of the following patterns of inheritance is most likely present with his disease?
A Autosomal dominant, European ancestry
B Autosomal recessive, Asian ancestry
C X-linked recessive, Middle Eastern ancestry
D Autosomal recessive, West African ancestry
E Sporadic occurrence
A 9-year-old previously healthy boy is noted by his teacher to be increasingly lethargic. He has not participated in games at recess for the past month. The boy says he always feels tired. Physical examination reveals no lymphadenopathy and no organomegaly. Laboratory studies show a Hgb of 9.8 g/dL, Hct 28.2%, MCV 95 fL, platelet count 74,000/uL, and WBC count 2300 with differential count of 23 segs, 15 bands, 12 monos, 44 lymphoblasts, 5 eosinophils, and 1 basophil. Which of the following enzymes is most likely to be increased on laboratory testing of cells from his blood?
A Glucose-6-phosphate dehydrogenase
B Leukocyte alkaline phosphatase
C NADPH oxidase
D Pyruvate kinase
E Tartrate resistant acid phosphatase
F Terminal deoxynucleotydyl transferase
A 29-year-old woman has had fatigue with dizziness for the past 5 months. On physical examination she has an erythematous malar rash. She has no lymphadenopathy, but there is a palpable spleen tip. She is afebrile. Laboratory studies show Hgb 8.9 g/dL, Hct 27.8%, MCV 105 fL, RDW 22, WBC count 8650/microliter, and platelet count 222,000/microliter. Her serum total bilirubin is 3.2 mg/dL with direct bilirubin 0.8 mg/dL. Her antinuclear antibody test is positive. Which of the following laboratory test findings is she most likely to have?
A Indirect Coombs test positive
B Increased serum ferritin
C Direct Coombs test positive
D Decreased reticulocyte count
E Increased osmotic fragility
An epidemiologic study is performed with diagnosed cases of malaria in children. The numbers of cases are plotted by geographic distribution. It is observed that more cases of malaria occur in a similar distribution to that of an infectious disease. Which of the following infectious agents is most likely to be associated with an increased prevalence of childhood malaria?
A Mycoplasma pneumoniae
B Parvovirus B19
C Plasmodium falciparum
D Hepatitis C virus
E Babesia microti
A 54-year-old man competes in the "Iron Man' triathlon on the big island of Hawaii. Following the race he is exhausted and collapses. Vital signs show T 39.6 C, P 101/minute, RR 21/minute, and BP 80/50 mm Hg. He has poor skin turgor. Laboratory studies show sodium 155 mmol/L, potassium 4.8 mmol/L, chloride 116 mmol/L, bicarbonate 26 mmol/L, glucose 70 mg/dL, and creatinine 1.5 mg/dL. Which of the following peripheral blood findings is he most likely to have?
A Basopenia
B Eosinophilia
C Lymphopenia
D Monocytosis
E Neutrophilia
F Polycythemia
G Thrombocytosis
A 25-year-old primigravida gives birth at term to a male infant. The infant is noted to be listless. Laboratory studies show that her hematocrit is 32% and the infant's hematocrit is 29%. Which of the following is most likely to be the mean corpuscular volume of their RBCs?
A 145
B 105
C 85
D 70
E 55
A 51-year-old man returns to the clinic several weeks after being placed on anti-hypertensive medications. He still has the lower abdominal pain that initially brought him to see a physician. His doctor notes that the CBC drawn on his first visit revealed a WBC count of 6600/microliter with WBC differential count of 62 segs, 4 bands, 22 lymphs, 9 monos, 2 eos, and 1 baso. His Hgb is now 11.3 g/dL, Hct 32.1%, MCV 75 fL, and platelet count 168,000/microliter. Which of the following is the most cost-effective test to perform at this point on this patient?
A Hemoglobin electrophoresis coagulation (DIC)
B Serum haptoglobin
C Antibody screen
D Stool guaiac
E Urinalysis
A 30-year-old woman has had mild fatigue for many years. Physical examination reveals a palpable spleen tip. Laboratory studies show Hgb 11.1 g/dL, Hct 28.8%, MCV 77 fL, platelet count 229,000/microliter, and WBC count 7340/microliter. Her reticulocyte count is 3.9%. Examination of her peripheral blood smear shows small RBCs that lack central pallor. Which of the following patterns of inheritance is most likely present with her disease?
A 32-year-old woman presents with fever and headache since yesterday. On physical examination she has diffuse purpuric areas on her skin. Laboratory studies show that her serum fibrinogen is 55 mg/dL. A CBC shows Hgb 13.3 g/dL, Hct 40.2%, MCV 93 fL, platelet count 11,500/microliter, and WBC count 34,600/microliter with WBC differential count of 38 segs, 8 bands, 5 metamyelocytes, 1 myelocyte, 41 promyelocytes, 5 lymphs, and 2 monos. A bone marrow biopsy is performed, and on microscopic examination the marrow is 100% cellular. A chromosome analysis is performed with cells from her marrow. Which of the following karyotypic abnormalities is most likely to be present?
A t(4;14)
B t(8;14)
C t(8;21)
D t(9;22)
E t(12;21)
F t(14;18)
G t(15;17)
A 22-year-old G3 P1 AB1 woman delivers a 3100 gm male infant at 34 weeks gestation. Apgar scores are 5 and 6 at 1 and 5 minutes. The infant and placenta are markedly hydropic. Laboratory studies show the infant has a neonatal bilirubin of 10.5 mg/dL with Hgb 8.3 g/dL. Which of the following laboratory test findings is he most likely to have?
A Positive indirect Coombs test
B Hypochromic microcytic RBC's
C Positive direct Coombs test
A 61-year-old man has noted fatigue and easy bruisability over the past 4 months. He has lost 4 kg without dieting. On physical examination he has rounded facies and a truncal redistribution of adipose tissue, with peripheral muscle wasting. A chest radiograph reveals a right hilar 4 cm mass with multiple 1 cm peripheral bilateral lung nodules. He has a 90 pack year history of smoking cigarettes. Which of the following peripheral blood findings is he most likely to have?
A 14-year-old boy had the sudden onset of dyspnea 2 days ago. He now has right sided chest pain. On physical examination he has dullness to percussion at the right lung base. There is right leg swelling and tenderness. Laboratory studies show Hgb 9.5 g/dL, Hct 28.6%, MCV 90 fL, platelet count 189,020/microliter, and WBC count 4130/microliter with 20 segs, 2 bands, 67 lymphs, and 11 monos. Urinalysis shows 3+ blood by dipstick but no RBCs on microscopic examination. The serum haptoglobin level is 4 mg/dL. His reticulocyte count is 3.9%. The direct and indirect Coombs tests are negative. Which of the following genes is most likely to have undergone mutation in this boy?
A Alpha globin
B BCL2
C Factor V Leiden
D G6PD
E HFE
F PIGA
G Prothrombin G20210A
A 56-year old woman has a routine health check-up. On physical examination there are no abnormal findings. Laboratory studies show Hgb 13.4 g/dL, Hct 40.2%, MCV 89 fL, platelet count 209,700/microliter, and WBC count 4990/microliter. Her total serum protein is 7.2 g/dL, and albumin 4.1 g/dL. A serum protein electrophoresis show a 2.7 gm monoclonal spike. Urinalysis reveals no Bence Jones proteinuria. A bone marrow biopsy is performed and on microscopic examination shows normal cellularity with maturing hematopoiesis and 5% plasma cells. A bone scan is normal. Which of the following is the most likely diagnosis?
A Heavy-chain disease
B Monoclonal gammopathy of undetermined significance
C Lymphoplasmacytic lymphoma
D Multiple myeloma
E Waldenström macroglobulinemia
A 59-year-old man has experienced fevers and progressive weight loss of 6 kg over the past 7 months. On physical examination his temperature is 37.6 C. His spleen tip is palpable. There are enlarged non-tender right inguinal lymph nodes. An abdominal CT scan shows splenomegaly and para-aortic lymphadenopathy. An inguinal lymph node biopsy is performed and on microscopic examination there are small lymphocytes, plasma cells, eosinophils, neutrophils, macrophages, and multinucleated cells. The multinucleated cells mark with an immunohistochemical stain for CD15. Which of the following is the most likely diagnosis?
A Disseminated tuberculosis
B Hodgkin lymphoma
C Langerhans cell histiocytosis
D Mycosis fungoides
E Sarcoidosis
A 68-year-old man has developed worsening abdominal pain for the past 2 days. On physical examination there is marked diffuse abdominal tenderness. Bowel sounds are absent. He has a temperature of 37.8 C. Laboratory studies show Hgb 13.8 g/dL, Hct 41.5%, MCV 87 fL, platelet count 227,800/microliter, and WBC count 39,400/microliter with 78 segs, 9 bands, 2 metamyelocytes, 1 myelocyte, 8 lymphs, and 2 monos. Examination of his peripheral blood smear shows neutrophils with toxic granulations and Dohle bodies. His serum glucose is 181 mg/dL and Hgb A1C 8.3%. His erythrocyte sedimentation rate is 55 mm/Hr. Which of the following is the most likely diagnosis?
B Ischemic enteritis
C Metastatic adenocarcinoma
D Mucormycosis
E Thalassemia major
A 42-year-old man has noted increasing abdominal enlargement for the past 6 months. On physical examination he is afebrile with BP 130/85 mm Hg. The abdomen is distended with a fluid wave. The spleen tip is palpable. He has palmar erythema and spider angiomata of the forearms. Laboratory studies show Hgb 12.1 g/dL, Hct 36.3%, MCV 103 fL, platelet count 188,800/microliter, and WBC count 5850/microliter. His total serum protein is 5.8 g/dL, albumin 3.3 g/dL, alkaline phosphatase 77 U/L, AST 82 U/L, ALT 71 U/L, and total bilirubin 1.3 mg/dL. Which of the following underlying conditions is the most likely cause for his splenomegaly?
A Alcohol abuse
B Diabetes mellitus
C Gaucher disease
D Injection drug use
E Leishmaniasis
F Metastatic adenocarcinoma
G Mixed connective tissue disease
A 26-year-old man has had fever and delirium for the past 2 weeks. On physical examination his vital signs include T 37.7 C, P 92/minute, RR 17/minute, and BP 95/65 mm Hg. He has right upper quadrant tenderness. There is a cardiac murmur. An abdominal CT scan shows mild splenomegaly with 3 wedge-shaped hypodense areas adjacent to the capsule. Laboratory studies show Hgb 13.3 g/dL, Hct 40.1%, MCV 93 fL, platelet count 197,200/microliter, and WBC count 14,230/microliter. A blood culture grows Streptococcus, viridans group. Which of the following underlying conditions is most likely to produce the splenic disease in this man?
F Myelofibrosis
G Trousseau syndrome
A clinical study is performed with subjects with hereditary hemochromatosis who have been treated with phlebotomy with removal of 1 unit of blood every 4 months for a period of 5 years. Complete blood counts with peripheral blood smears and WBC differential counts are performed on these subjects and the test results analyzed. Which of the following laboratory findings is most likely to be present in these subjects?
A Eosinophilia
B Hypochromasia
D Megaloblastic changes
F Reticulocytosis
G Thrombocytopenia
A 70-year-old woman has had increasing lethargy for the past year. She noted that her skin complexion is darker even though she spends little time outdoors. On physical examination she is afebrile. Her blood pressure is 165/105 mm Hg. Laboratory studies show serum creatinine 4.4 mg/dL, urea nitrogen 42 mg/dL, and glucose 74 mg/dL. An ultrasound scan shows markedly enlarged, cystic kidneys bilaterally. Which of the following sets of peripheral blood findings is she most likely to have?
A Hgb 8, MCV 70, Plt Ct 200,000/uL, WBC Ct 5500/uL, reticulocytes 3.2%
B Hgb 10, MCV 80, Plt Ct 225,000/uL, WBC Ct 6500/uL, reticulocytes 0.3%
C Hgb 12, MCV 85, Plt Ct 100,000/uL, WBC Ct 4500/uL, reticulocytes 2.3%
D Hgb 14, MCV 90, Plt Ct 250,000/uL, WBC Ct 8500/uL, reticulocytes 1.1%
E Hgb 16, MCV 95, Plt Ct 500,000/uL, WBC Ct 7500/uL, reticulocytes 1.5%
F Hgb 18, MCV 100, Plt Ct 150,000/uL, WBC Ct 9500/uL, reticulocytes 4.4%
A 33-year-old man has been receiving chemotherapy following removal of a mixed germ cell tumor of his left testis. He developed a urinary tract infection from his indwelling catheter and received antimicrobial therapy with trimethoprim-sulfamethoxazole. A week later laboratory studies show Hgb 12.8 g/dL, Hct 38.5%, MCV 91 fL, platelet count 193,400/microliter, and WBC count 1970/microliter with differential count of 10 segs, 76 lymphs, and 14 monos. Which of the following pharmacologic agents will be most useful in treating this man?
A Deferoxamine
B Epoetin alfa
C Ferrous sulfate
D Filgastrim
E Folic acid
F Oprelvekin
G Thrombopoietin
H Vitamin B12
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